Janis Newman, a retired teacher living in Garland, TX, had been expecting to see her neurologist, Waleed H. El-Feky, MD, at his office in Dallas on April 1 for an appointment to check her medications. Newman, 72, had begun experiencing seizures and restless legs syndrome in her sixties, but both conditions were under control with Dr. El-Feky's management.
A week before the appointment, she received a call from Dr. El-Feky's nurse: The office was closed to all nonemergency patients because of the COVID-19 outbreak, but they could offer her a virtual visit. "I had some experience with teleconferencing, so it sounded perfect to me," says Newman.
At the originally scheduled time of her appointment, Newman logged on to Texas Neurology's online portal on her iPad, using a passcode the office had emailed to her. "At first there was a glitch and we couldn't see each other, but that only lasted about a minute," she says. "He asked me all the usual questions, and we talked about how my medications are working. He also asked for my weight, pulse, and blood pressure, which I was able to give since I have a blood pressure machine at home."
Newman says she'd be happy to do more telehealth visits even after the pandemic is over. "As long as there's no medical reason to go in, [a video call] is so much easier than driving and sitting in the waiting room."
With medical practices, hospitals, and health systems postponing nonurgent visits indefinitely, many people with neurologic conditions, like Newman, will probably have at least one appointment via telehealth.
Even after the shutdown ends, telemedicine will continue to some extent. "We are learning what it is and isn't appropriate for," says Neil A. Busis, MD, FAAN, clinical professor of neurology and associate chair of technology and innovation at NYU Langone Health. "If you're having positive experiences or if you've had problems [with telehealth], tell your doctor. We're crowdsourcing this process, and patients are a vital partner in defining the next era of health care."
Just like an in-person appointment, an audiovisual visit often begins with the neurologist inquiring about a patient's progress, concerns, medications, and follow-up related to the previous visit. It then moves on to the physical examination. For patients with neuromuscular disease, a pediatric neurologist like Bruce Cohen, MD, FAAN, director of the NeuroDevelopmental Science Center at Akron Children's Hospital in Ohio, may assess the patient's eye movements, hip strength, walking, and coordination. "Most of that is easy to do over video," he says. "Since I can't have patients hold up their arms and ask them to resist as I try to push them down, I do functional muscle testing. I may ask a patient to lift hand weights or try to do a push-up. There are many tests I can use virtually to get an idea of how strong or weak a patient is."
In preparing for a telemedicine appointment, you can ensure it will be as productive as possible by knowing what to expect and what to do in advance.
Determine the Tools
For most neurologic exams, it's important that your doctor can see you and vice versa. This means you will need a smartphone, a laptop or desktop computer, or a tablet, such as an iPad. "Any device with a camera and a screen will give you access," says Emile S. Moukheiber, MD, assistant professor of neurology at Johns Hopkins Medical Center and a member of the telemedicine study group for the Movement Disorders Society.
"A key component is connection speed," says Dr. Moukheiber, who notes that download speed should be at least five megabits per second (Mbps). "Those who don't have home internet can often rely on a 3G or 4G wireless connection on their smartphone."
It's best to have a backup device in case your primary one doesn't work, Dr. Moukheiber adds. If all device connections fail, you can always continue the visit by telephone.
The telephone could be all the equipment needed for some virtual visits, especially for quality-of-life issues like depression and anxiety where patients may benefit from a familiar voice, a referral to a therapist, and a prescription, says Dr. Busis.
Understand the Technology
Prior to your appointment, your neurologist's office should send you instructions for connecting securely to its online portal or downloading an app if needed. Familiarize yourself with the app or website in advance, and make sure your computer or phone is set to allow notifications and use of the camera and microphone during your appointment.
Because COVID-19 has been declared a national health emergency, privacy restrictions for telehealth communications have been relaxed temporarily, permitting some providers to use software that isn't compliant with HIPAA privacy protections, such as FaceTime, Skype, or WhatsApp. Other platforms specifically designed for telehealth consultations include VSee, Doxy, Thera-Link, and Amazon Chime.
On your doctor's or health practice's telehealth system, you might find a setup similar to the website and app used by NYU Langone Health, which has been conducting thousands of virtual visits every day—many in neurology—since mid-March. "Patients have a calendar of their telehealth appointments, which they can click on and enter a virtual waiting room, where the doctor gets a notification," says Dr. Busis. "You can also send your doctor messages and attach images."
Set Up Your Space
Designate an area in your home for your telehealth visit. "Choose a place that can be closed off, so you'll have privacy and minimal distractions," says David A. Evans, CEO of Texas Neurology. "Ideally, you should have room to walk back and forth so your neurologist can ask you to perform certain tasks to assess your mobility and function." You also should ask about what to wear. Many neurologists recommend slippers, shorts, and a T-shirt so they can see your arms, legs, and feet.
Gather everything you'll need for the appointment ahead of time, including your medications (or a list of them), lab or imaging results, your list of questions for the neurologist, and any items your neurologist has requested, such as hand weights, a flashlight, a tape measure, or a blood pressure cuff.
Because you need to have both hands free for at least part of the exam, find a spot in the room where you can place your phone or tablet at eye level—or ask a companion or family member to hold the device and move it around when necessary. Be sure you have good lighting and that windows or other light sources are not behind you as you face the camera. "Natural light shows more of your true skin tone," says Dr. Moukheiber, noting that this is important for neurologic conditions that may affect skin color, such as nerve damage that causes discoloration.
"Remember that the camera has to be reversed, like you're taking a selfie," says Elaine Jones, MD, FAAN, a full-time telehealth neurologist with SOC Telemed who practices from her home office in South Carolina. "Make sure your sound is turned up and speak loudly and clearly so you and your provider can hear each other."
Buddy Up
It's always helpful to have someone with you during the visit. The person can adjust the computer or phone, modify lighting, and handle any technical difficulties. This person can also take notes and help you remember important information. For people with dementia, a caregiver can answer questions and help the patient participate in the visit.
Be Aware of Limits
"Detailed sensory testing is more difficult," says Dr. Jones, "but we can ask patients if they think there is numbness in a leg or arm, then ask them to rub the affected limb and tell us where it starts to feel normal." Patients can also use a toothpick to test pin sensation and a Q-tip or cotton swab to test light touch.
Sometimes, though, a patient must be assessed in person. Dr. El-Feky cites a patient who was experiencing visual problems, with dark objects that neurologists call scintillating scotomas recurring in her field of vision over five days. "These are commonly associated with migraine, but the fact that they were so persistent for so long suggested to me that she might need a full eye examination with fundoscopy, which illuminates the retina, to rule out problems with the optic nerve or a small stroke," he says. "If these visual defects don't go away with migraine therapies, I'll arrange an in-person visit for testing."
Dr. Cohen says that for most of the patients he's seen virtually thus far, he's obtained all the information he's needed to make medical decisions. "That said, I've still had several patients for whom face-to-face appointments were required, such as a new brain tumor diagnosis and a child with a stroke."
How to Pay for Telemedicine Visits
Even as medical practices and health systems begin to re-open and welcome patients for in-person visits, telehealth appointments continue to be the dominant method of proving care. And as patients and doctors get used to the technology, they are learning how to make each visit more efficient and meaningful. They are also learning more about how to pay for these interactions.
Traditionally, Medicare covered telehealth visits only for people living in rural areas who use videoconferencing at a local medical facility to connect with experts at other locations. Virtual visits from a patient’s home were generally not covered. And most private insurers followed Medicare’s lead.
But COVID-19 has changed that. Advocacy efforts by medical organizations, including the American Academy of Neurology, have led to the expansion of telehealth benefits under Medicare and many private insurance companies. Now Medicare covers many telehealth visits—including office consultations, mental health counseling, and preventive screening—in your home (as well in doctor’s offices and long-term care facilities).
In many cases, copays and other out-of-pocket costs for all telehealth visits (not just those related to COVID-19) have been waived, at least temporarily, by insurers including Humana, Aetna, and Blue Cross Blue Shield. Medicare has also said that its providers may waive copays for telehealth visits not related to COVID-19. But specific policies for coverage, preauthorization, and copays still vary based on insurer and the state you’re in, so check with your health insurance company to find out what is available to you.